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Health Care Up to Public, Edwards Says

John Edwards, who campaigned Thursday in Anderson, S.C., has made health care one of his signature campaign issues.Credit
Jacob Silberberg for The New York Times

PATRICK, S.C. — Former Senator John Edwards does not discount the possibility that his health care proposal, which would allow Americans to buy new government insurance packages modeled on Medicare, could evolve into a federalized system like those in Canada and many European countries. And if it does, Mr. Edwards said he would be just fine with that.

But Mr. Edwards, of North Carolina, emphasized in a 40-minute interview on health policy that the choice would be made not in Washington, but by consumers in an open marketplace where private insurance competes with government plans.

“American health consumers will decide which works best,” Mr. Edwards said Wednesday afternoon while traveling through South Carolina on his campaign bus. “It could continue to be divided. But it could go in one direction or the other, and one of the directions is obviously government or single-payer. And I’m not opposed to that.”

Each of the three Democratic front-runners has called for government insurance that would be available to an expanded number of consumers, not just the elderly and disabled as is currently the case with Medicare. If the government is able to undercut private insurers on price — by forgoing profit, reducing overhead, and maximizing economies of scale — it theoretically could put the private system out of business and become the de facto insurer for the nation.

Mr. Edwards brushed off that critique. “There is nothing back-door about it,” he said. “It’s right through the front door. We’re going to let America decide what health care system works for them.”

Karen Davis, president of the Commonwealth Fund, a foundation based in New York that researches health policy, said most countries with single-payer systems adopted them before private insurance took hold, and that none evolved through the marketplace. She agreed, however, that a Medicare-style plan would compete ferociously with private plans on price.

Though he was the Democratic vice-presidential nominee in the presidential campaign of Senator John Kerry in 2004, Mr. Edwards has yet to win a primary or caucus, and is polling third before Saturday’s Democratic primary here in his birth state. Regardless of his prospects, he argues that his populist campaign has driven his party’s debate on health care by being the first to produce a comprehensive plan intended to cover all 47 million uninsured.

That, he maintained, had forced Senators Hillary Rodham Clinton and Barack Obama to follow with their own detailed proposals. “It makes it very difficult for other candidates to float through on rhetoric,” he said.

Mr. Edwards spoke comfortably about both the philosophical underpinnings and policy details of the health coverage debate. Whether or not he can claim credit for leading the discussion, a virtual Democratic consensus has formed around the major elements he has proposed, and around the notion that government, businesses and individuals should share the financial burden.

Mr. Edwards did not propose a universal coverage plan when he ran for president in 2004, focusing instead on expanding enrollment of children. But a day after the Kerry-Edwards ticket lost, his wife, Elizabeth, was found to have breast cancer, and his family began its first-hand education in the vagaries of the system.

“I mean, when you get the statements by the providers and the insurance companies about what’s covered and what’s not covered, even for two people who are well versed in the law and experienced with the health care system, it seems completely arbitrary in many cases,” said Mr. Edwards, a lawyer. “It doesn’t make any sense.”

The public nature of Mrs. Edwards’s illness — she announced a recurrence at a news conference last year — drew people with health care horror stories to the Edwards campaign. As health care costs and the number of uninsured continued to rise, Mr. Edwards sensed that people were ready for more radical surgery on the insurance system.

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“I concluded that something bolder was needed, that the health care system had become increasingly dysfunctional,” he said. “And my contact with a lot of uninsured Americans, who were not children, made it clear to me that the plan had to be universal, that it had to cover everybody.”

For advocates of universal health care, the threshold question is whether the existing public-private system can be revamped to make insurance affordable for all, or whether that can be achieved only through a government takeover.

Mr. Edwards said he strongly considered a single-payer plan before announcing his initiative last February.

“I thought that there was a legitimate and strong argument for it,” he said. “But I also believed that there are an awful lot of Americans who like the health care they have and are nervous about entirely government-controlled health care.”

Under Mr. Edwards’s proposal, which resembles the plan adopted in Massachusetts in 2006, the government would require individuals to have insurance (illegal immigrants excepted). It also would prohibit insurance companies from rejecting high-risk applicants and would restrict their profits and overhead to 15 percent of revenue from premiums.

Government subsidies and tax credits would be available to low- and middle-income families that cannot afford insurance. Those below the federal poverty line — currently $21,200 for a family of four — would get free coverage, Mr. Edwards said. Those making less than 250 percent of the poverty level — currently $53,000 — would be heavily subsidized and there would be some financial help for those making up to about $100,000.

Employers that do not offer medical benefits to their workers would have to contribute 6 percent of their revenues to the regional government pools that would offer Medicare-style plans. Midsize businesses and employers with large numbers of low-wage workers might be asked to pay less, and the smallest businesses would be exempt, Edwards aides said.

To pay for those subsidies, which account for much of the estimated $90 billion to $120 billion cost of the plan, Mr. Edwards would rescind President Bush’s income tax cuts for those with incomes above $200,000. Additional revenue would be produced through a broad menu of cost-control measures.

Like his opponents, Mr. Edwards would promote preventive medicine and chronic-disease management and require doctors and hospitals to convert to electronic record-keeping.

Mr. Edwards has joined with Mrs. Clinton in arguing that Mr. Obama’s plan would not provide universal coverage because it mandates insurance only for children, as Mr. Edwards did in 2004.

But Mr. Edwards’s own mandate would not take effect until insurance is considered affordable. He could not define how or when that might be determined. Thus far, that has been a critical shortcoming of the plan in Massachusetts, where thousands of residents may be exempted from the insurance requirement because they cannot afford even subsidized premiums.

Mr. Edwards has not proposed such exemptions. He said that those who do not have insurance would be required to obtain it whenever they come into contact with a health care provider or government services office.

A version of this article appears in print on , on Page A21 of the New York edition with the headline: Health Care Up to Public, Edwards Says. Order Reprints|Today's Paper|Subscribe